When is an Injury Deemed a Disability for the Purpose of Insurance?

In Florida, as in other states, there are a variety of private insurance plans for disability coverage, each with their own respective terms and provisions relating to such disability coverage. If you are suffering from an injury or other health condition that has rendered you disabled (partial or full), however, then you may find that your insurer — despite having provided you “comprehensive” coverage — has wrongfully denied benefits to you on the basis that your injuries/condition do not qualify as a disability under the plan.

You have a number of different options: a) you can resubmit your original application if your documentation was inadequate, or if there was some other procedural issue; b) you can challenge the denial of your original claim through the appeal process; or c) after you have exhausted administrative remedies, you can bring a lawsuit against the insurer for wrongful denial of benefits (and perhaps for bad faith conduct).

So, what counts as a disability, and what is defined as a non-disabling condition? Let’s take a look.

Each Plan Has Its Own Rules

Your disability policy may differ from others, so it’s important that you have a qualified attorney assess the language of the contract. Whereas one disability coverage plan may have a broader definition of “disability,” another may have a narrow definition — it’s critical that you understand the range of conditions that your plan covers.

Typical Disability Factors

Generally speaking, you will be entitled to receive disability benefits if you can show that you have a condition that prevents you from working. If your disability coverage is short-term, then you will be entitled to receive benefits even if the condition is limited in duration. If your disability coverage is long-term, on the other hand, then you will only be entitled to receive benefits if the condition significantly interferes with your work-related activities for a year or more (depending on the plan).

Remember, each plan is different. The following factors may influence the determination of whether you are actually disabled.

Whether you have other sources of income and are making a certain threshold level of income per month;

Whether your condition interferes with basic work-related activities;

Whether your condition prevents you from performing alternative work-related activities, and whether you have sufficient education, training, and experience necessary to transfer your skills to another position;

Whether your condition fits into a specified list of disabling conditions included in the insurance contract;

And more

In many cases, despite the fact that a person is covered by private disability insurance, their insurer will attempt to avoid paying out by denying their disability claims or by delaying payment so as to frustrate the efforts of the policyholder. Wrongful denial of benefits is a serious civil offense, and could expose the insurer to additional liabilities. If you have been wrongfully denied disability benefits by your insurer — perhaps on the basis of your injury/condition not being deemed a disability pursuant to the insurer’s interpretation of the plan — then you may be entitled to compensation for such denial, in addition to your rightful benefits.

Ver Ploeg & Lumpkin is a Florida insurance litigation firm that has represented clients in insurance disputes for more than two decades, from the wrongful denial of benefits to bad faith insurance litigation. Our attorneys are well-equipped to help policyholders obtain the benefits that they are entitled to.